Does telehealth influence the decision to transfer residents of residential aged care facilities to emergency departments? A scoping review

Abstract Background Emergency Departments (ED) can be crowded places and not ideal environments for Residential Aged Care Facilities (RACF) residents awaiting assessment. Assessment and care planning may be made available via telehealth thereby avoiding unnecessary transfer to ED, without compromising the quality of care for the older person. Telehealth is attractive addition to improving healthcare decision‐making in RACFs. Objectives The aim of this scoping review is to explore the evidence around the use of telehealth and whether it influences the decision to transfer residents of RACF to ED. Methods All peer reviewed literature that focused on RACFs, decision‐making and assessment of residents using telehealth in real time, was included. All study designs, pilot studies and some systematic reviews were considered. Databases Medline, Embase and CINAHL were used in this search in June 2022. Search terms were a combination of the population: RACF residents, decision‐making and assessments using telehealth, and or transfer to the ED. The search was assisted by a senior university research academic librarian/information specialist and reviewed by senior researchers. The PRISMA‐ScR guidelines were used to report this study. Results Of the 124 articles initially identified, 31 were eligible for inclusion for synthesis. The date range of the included studies was 2001 to 2022, with 15 published in the last five years. Critical appraisal was conducted using the Mixed Methods Appraisal Tool. Conclusion This scoping review has mapped evidence that telehealth has been widely used in multiple settings. The association between the use of telehealth with improved clinical outcomes highlights its potential utility in enhancing care delivery for an older population in RACFs. Telehealth has shown that it can improve the decision‐making for residents in RACFS, but more robust research designs are needed. Implications for practice Using video/telehealth appears to improve RACF staff access to expert clinicians who can then assess and jointly plan care/management that can be provided in the resident's home. Knowledge and skills of RACF staff appear to be improved through joint assessment and decision‐making with the use of video/telehealth access to expert clinicians.


| INTRODUC TI ON
Hospitalisation of residential aged care facility (RACF) residents can potentially affect their quality of life, expose them to unnecessary health risks and increase their mortality and morbidity. Emergency departments (ED) can be crowded places and not ideal environments for residents awaiting assessment. With prolonged wait times and length of stays (LOS) in ED, residents are at risk of iatrogenic complications and adverse events (Grant et al., 2020). It would be beneficial for RACF residents to have access to viable alternatives to ED thereby avoiding unnecessary health risks. Alongside the risk of being in ED, is the fact that the resident's visit may have been unnecessary, as found in studies in the United States and Canada, where 67% and 25% (respectively) of RACF-resident presentations were potentially avoidable (Gillespie et al., 2019;Grant et al., 2020).
Alternative care pathways and health management plans for RACF residents rather than an unnecessary and risky hospital visit is worthy of consideration. Cost-effective strategies like telehealth are an attractive addition to improving the provision of healthcare within RACFs (Chan et al., 2001). Telehealth may support the RACF staff to make better decisions about the care required and available care options. There is evidence that adding a visual assessment to a telephone consultation can improve the quality of care and clinical decision-making (Jarvis-Selinger et al., 2008) for RACF residents.
The Internet boom has led to the expansion of telehealth/telemedicine applications available for use globally (WHO, 2009), which has made telehealth technology more accessible.

| BACKG ROU N D
There are many descriptions of telehealth that identify it as mobile and dynamic communication tool, adaptable to the medical needs of the care recipient in many ways and across many contexts. Telehealth and telemedicine are terms that are often used interchangeably. For the purpose of this paper, we will refer to any interaction that uses real-time visual assessment consultation as telehealth, including telemedicine. They are both performed in real time involving synchronous data transmission. Telemedicine is often used to describe occasions where there is a physician or health professional who is assessing and prescribing treatment via the use of telehealth (WHO, 2009). Telehealth fits with the definition from the International Organisation for Standardisation that population in RACFs. Telehealth has shown that it can improve the decision-making for residents in RACFS, but more robust research designs are needed. Implications for practice: Using video/telehealth appears to improve RACF staff access to expert clinicians who can then assess and jointly plan care/management that can be provided in the resident's home. Knowledge and skills of RACF staff appear to be improved through joint assessment and decision-making with the use of video/ telehealth access to expert clinicians.

K E Y W O R D S
care homes, care of older people, decision-making, emergency Department, gerontological Nursing, long-term care, residential care, telehealth, transfer

Summary statement of implications for practice
What does this research add to existing knowledge in gerontology?
• This scoping review has mapped evidence describing the use of telehealth-aided decision-making in multiple settings.
• Residents are transferred out of their home when staff are unable to make confident, informed decisions about the management/treatment of the resident, in situ, in their own home.
What are the implications of this new knowledge for nursing care with older people?
• Using video/telehealth appears to improve RACF staff access to expert clinicians who can then assess and jointly plan care/management that can be provided in the resident's home.
• Knowledge and skills of RACF staff appear to be improved through joint assessment and decision-making with the use of video/telehealth access to expert clinicians.
How could the findings be used to influence policy or practice or research or education?
• More research using robust study designs needs to be undertaken to support or refute the hypothesis that video/telehealth can improve health outcomes for residents in RACFs.
• Cost savings can be made if residents are able to receive expert care and support in their own home rather than transfer to an ED.
• Providing care for residents in their own home should become recommended government policy. defines telehealth as the use of telecommunication techniques for the purpose of providing telemedicine, medical education and health education over a distance (ISO, 2021).
Telehealth provides a way of reducing inequalities in health care by delivering knowledge, resources and skills to support staff in rural communities where they do not have ready access to clinical expertise (Nesbitt, 2012). Teleradiology is an example of a critically important acute care telehealth service provided to rural hospitals to assist in the rapid diagnosis of patients with traumatic injuries and strokes. Telestroke is a model telehealth service because of its documented improvements in patient outcomes and the strong economic case that can be made for implementing the service (Weinstein et al., 2014).
Teletrauma, teleburn and telestroke programs (Weinstein et al., 2014) bring capability and urgent assessment and treatment to areas that do not have such specific clinical expertise.
In ophthalmology and optometry, non-mydriatic cameras can be used to perform retinal screenings in people with diabetes without needing to dilate the eyes, and this has increased screening rates. Correctional telehealth contributes to not having to transport prisoners to outside clinics and protecting public safety (Weinstein et al., 2014). Examples of telehealth include, but are not limited to, telepaediatrics, telecardiology, teledermatology, teleinfectious disease, teleneurology, teleophthalmology, telepathology, telepulmonology, telepsychiatry, telerheumatology and telenursing (Weinstein et al., 2014).
In recent years, there has been a rapid uptake of technology internationally. This has intensified the scope and availability of telehealth, utilising Web-based applications (e.g. e-mail, teleconsultations and conferences via the Internet) and multimedia approaches (e.g. digital imagery and video) (WHO, 2009). Staff and patient satisfaction have increased in the past few years, probably due to familiarity with, and improvements to technology (Weiner et al., 2001).
Despite these technological advances, the use of telehealth has not progressed as rapidly as expected.
Despite the availability of ready to use telehealth devices in industrialised and developing countries (Wootton, 2008), the process of activating telehealth conversations is not straightforward (Weinstein et al., 2014). Reasons for this are reported to be the lack of standards (Nesbitt, 2012), poor progress once initial 'seed' money dries up (Wootton, 2008), lack of financial incentives and poor technology integration (Weinstein et al., 2014). There is also the problem of competing workload commitments for the staff in RACFS caring for residents with higher health needs who require extensive support (Gillespie et al., 2019). Furthermore, it is challenging to maintain the clinical skills needed for RACF staff when there are high staff turnover rates (Gillespie et al., 2019), this is a valid concern for implementation planning. In addition, negative staff attitudes towards telehealth can have an impact on telehealth implementation (Crundall-Goode & Goode, 2014).
This paper presents a scoping review of the literature to identify evidence of the effectiveness and experience of telehealth use in RACFs to assist the decision-making of RACF staff regarding the transfer of the resident to ED. Limited literature seems to be available describing or evaluating how a telehealth model of care can prevent RACF residents from presenting to EDs. A scoping review of the literature will identify what information is available in all clinical areas to understand the barriers and enablers to telehealth, and if telehealth improves the clinical decision-making, and how an intervention can be implemented successfully into practice.
A scoping review is considered less restrictive than a systematic review with search criteria allowing a broader scope for literature searches (Munn et al., 2018). In addition, in a scoping review, information can be drawn from any source and is not restricted to quantitative studies (Munn et al., 2018). In the case of RACF-resident transfers to ED, a scoping review will be invaluable in identifying existing evidence (Munn et al., 2018) and help the reader understand the key concepts and concerns of an approach rather than describe the efficacy and viability of interventions that a systematic review provides. The scoping review potentially provides an overview or a map of the evidence and clarification of definitions (Munn et al., 2018).

| Aim
The aim of this scoping review is to explore if the use of telehealth and whether it influences the decision to transfer residential aged care facilities residents to emergency departments.

| ME THODS
Our protocol was developed using the scoping review methodological framework proposed by Arksey and O'Malley (2005) and further refined by the Joanna Briggs Institute (JBI) (Peters et al., 2020).
A scoping review of the literature as outlined by Arksey and O'Malley (2005) was undertaken to examine the extent, range and nature of the research undertaken in this area, to assist in summarising the research findings, and identify gaps in the existing literature. As Peters et al. (2020) describe, scoping reviews differ from other reviews in that, they are used to present a broad overview of the evidence, regardless of the quality of the study and are considered a precursor to a systematic review. They are useful to uncover emerging data, clarifying key concepts and identifying gaps (Peters et al., 2020). The Scoping review was completed in six stages as recommended by (Arksey & O'Malley, 2005)  This study followed the Preferred Reporting Items for Systematic reviews and Meta-analysis Extension for Scoping Reviews (PRISMA-ScR) guidelines (Tricco et al., 2018) see File S1 and the ENTREQ Statement (Enhancing the transparency in reporting the synthesis of qualitative research) File S2.

| Search strategy
The search strategy for this scoping review was developed with assistance from a university research librarian/information specialist, following the JBI framework to determine eligibility of the search question (Peters et al., 2020) including studies that assessed; 1. The population: RACF residents (65 years or older), 2. Concept: decision-making and assessments using telehealth, 3. Context: transfer to the ED.
The full electronic search strategy was refined in the Medline database, including any limits used, such that it could be repeated and is presented in File S1. These search terms were also used in subsequent searches of databases, Embase and CINAHL, with all papers fitting search criteria to July 2022. All relevant articles retrieved from this search strategy were included for screening. Additional studies were identified by manually searching the reference lists of potentially relevant papers and other telehealth/telemedicine systematic reviews. All articles identified were imported into Covidence Systematic Review Software for screening File S3.

| Inclusion criteria
All peer reviewed literature that focused on RACFs, decision-making and assessment of residents using telehealth in real time were included. All study deigns using recognised methods of data collection and data analysis including, some pilot studies and some systematic reviews were considered, and only studies reporting evidence relating to RACFs were included. Studies were included if they were in English language only.

| Exclusion criteria
Articles not pertaining to telehealth, decision-making or integrating patient care in real time with telehealth were not included, along with discussion papers/editorials or papers which only have abstracts available.

| Title and abstract
Title and abstract screening was completed in Covidence Systematic Review Software. The inclusion criterion was followed as above, for the title and abstract screening. Review articles, conference abstracts, posters, editorials and commentaries were excluded from the review.

| Full text screening
Full text screening was also completed in Covidence Systematic Review Software. Papers included were based on blinded review by two authors using the following four main concepts: 1. Telehealth, telemedicine (visual/video/real-time); 2. Nursing homes, long-term care homes, RACFs or alternatives; 3. Decision-making and/or assessment; 4. Emergency service and/or alternative.
When the screening was completed by two independent reviewers, the conflicts were managed and resolved by discussion between the two reviewers, including a third reviewer when necessary.

| Data extraction and analysis
A data extraction form on Microsoft Excel was used to guide the collection of information from each article. The following descriptive data were extracted from each article that satisfied the inclusion criteria: year of publication, language, country, study design and study setting. For completed studies (not protocols), participant demographics were extracted, including number of participants, and participant age and sex. With respect to telehealth, we extracted information about persons who undertook telehealth consultations, and assessment. All outcomes and variables that studies assessed for a telehealth relationship with RACF residents, assessment and emergency were recorded. As numerous outcome variables were identified, outcomes were grouped according to overarching themes for the purpose of analysis.

| RE SULTS
Our database search retrieved 4939 articles and hand-searching identified 25 additional articles for a total of 4964. After duplicates were removed, articles were included for title and abstract screening. We screened the full text of 124 articles these were further assessed till we were able to retrieve 31 papers for this scoping review that fitted our criteria. The findings from this search process are presented in Figure 1.

| Critical appraisal of individual sources of evidence
The quality of the reported studies was appraised using the mixed methods appraisal tool (MMAT) (Hong et al., 2018). The rationale for using the MMAT tool was that it was able to assist appraisal across different study designs and methodologies using only one tool. The MMAT tool was created and validated to assess the methodological quality of five categories of studies: qualitative research, randomised controlled trials, non-randomised studies, quantitative descriptive studies and mixed method studies (Hong et al., 2018).
Whereas it is not mandatory to utilise a tool for critical appraisal in a scoping review, the authors felt that the inclusion of the MMAT would provide rigour, reduce bias and a uniformed approach towards appraisal of the studies found.
The MMAT (Hong et al., 2018) measures overall quality, with two initial questions where further appraisal may not be needed if the answer is no to one or both screening questions. All the papers were critically appraised by the first author and divided up evenly between the other authors of this paper, so all studies were appraised by two people independently. Any discrepancies were discussed until a consensus was reached. Six of the papers were identified as poor in quality (scoring 4 or below) but were still included in the Evidence Table (Table 2).

| Data charting process
An overview of each included paper is provided in Table 1. This evidence table provides further details of the authors, year of publication, country, context, aim, study design, sample data collection methods and analysis, outcomes/ findings, MMAT score and limitations.

| Description of studies
Authors of the 124 articles identified for full text review, 31 were eligible for inclusion in our synthesis and are presented in the Evidence Country, the various countries represented in this review are described in the Evidence Table (Table 1). Most studies were from the United States (n = 15) followed by Hong Kong (n = 4) and Australia (n = 3), two each from Singapore, France and the UK, and one each from Germany, Italy and Canada.
Aim, the studies aimed to determine if telehealth; lowered rates of hospitalisations, reduced adverse events, was cost effective, was an acceptable service, improved health outcomes, linked people to appropriate services, was an effective and efficient intervention, and strengthened communication links. Further to this, studies also aimed to understand; clinical staff perception of telehealth, what it was being used for, the benefits, barriers and enablers, how much activity was going on, and the care givers' experiences.

Data collection methods and analysis
MMAT score, Critical appraisal using the MMAT (Hong et al., 2018) resulted in 13 of the studies receiving a rating of good, 12 were rated as fair, and 6 were rated as poor due to low methodological quality. The data are presented in Table 2.
Limitations, of some studies included that seasonality was a confounder for hospital presentations, poor coding, and data collection issues, difficult to embed the intervention due to staff turnover, physical examination limitations, difficulties engaging with GPs, small sample sizes meaning the study findings were not generalisable, and some studies made claims of reductions in events without providing any numerical or statistical data.

| Findings
For the qualitative analysis, two authors conducted the initial categorisation of the key components independently, using NVivo (QSR, 2020) and manually, then presenting the results to the team for discussion. A framework was established through team discussions upon reviewing the preliminary results as a guide, as recommended by JBI. Categories were then identified, coded and charted TA B L E 2 MMAT study rating
Analysis of the 31 studies, identified five common findings: 1.
Older person (resident) hospital avoidance, 2. Older person (resident) experience, 3. Nurses' improved assessment skills, 4. Cost savings, and 5. Barriers and enablers. The five findings are presented in the following section.

| Older person (resident) hospital avoidance
Most of the papers identified increases in hospital avoidance as an outcome measure. However, only two studies used robust research designs with low risk of bias, including an RCT (Joseph et al., 2020) and a Stepped wedge RCT (Stern et al., 2014). These two trials reported conflicting results. The Joseph et al. (2020) RCT found that the telehealth groups were less likely to have their care escalated to a hospital than the control groups that has no telehealth service 27% vs 71% (OR 0.15, CI 0.13-0.17); whereas the Stern et al. (2014) Stepped Wedge RCT did not find a significant difference in hospitalisation rate and it was estimated to be 1.2 (CI 0.62, 2.36) times more(p = .59) with the use of telehealth.
The Hofmeyer et al. (2016) pilot study found that 69% of 511 telehealth consults could be managed without an ED transfer. In a descriptive study by Low et al., (2020), keeping the resident in the RACF after the telehealth interaction was perceived to be a successful outcome; 'Within a month after the consultation, 83.6% of 1399 consultations had the patients (sic) remaining in the nursing home' (Low et al., 2020(Low et al., , p. 1075. In other studies, a small pilot study found that hospitalisation was less common in 29% (n = 11) of residents in whom the telehealth recommendations were followed (Catic et al., 2017), and in a mixed method study, 75.6% (n = 378) avoided transfer to hospital (Salles et al., 2017). In a case study examining identification of residents with urgent podiatry problems (Corcoran et al., 2003), there was earlier identification and avoidance of serious problems with the use of telehealth that would otherwise have necessitated a hospital admission (Bidmead et al., 2015). In a descriptive study that measured just the physicians' impressions, it was reported that they had confidence that telehealth would impact on hospital avoidance (Driessen et al., 2016;Laflamme et al., 2005). This finding was also confirmed in a retrospective cohort study by Roques and Hovanec (2002, p. p 37). The authors claimed that 'During the first year of operation of the Telemedicine program, there were fairly dramatic changes in the number of hospitalizations (1997 n=21, 1998 n=11) and the total number of days spent in the hospital (1997 n=367, 1998 n=258)' (Roques & Hovanec, 2002, p. 37).

| Older persons' (resident) experience
Seven of the included studies reported on the residents' experience of telehealth. Pilot studies (Chan et al., 2001;Hui et al., 2001) considered the resident experience to be positive and acceptable.
Resident satisfaction was measured through surveys and interviews, all reporting a positive experience in terms of usability and acceptability of telehealth (Chan et al., 2001). A case study interviewed residents about telehealth. Residents indicated that they felt less distress and increased comfort and they felt it gave them a better quality of life with the use of telehealth (Bidmead et al., 2015).
Importantly, a cohort study found that residents also felt more included in decision-making with telehealth (Chess et al., 2018).
Further, a descriptive study utilising a survey found that residents regarded communication via telehealth made it easy to state their concerns (Prandi et al., 2020).
Important insights were provided in a descriptive study (Corcoran et al., 2003), that reported a preference for telehealth over personto-person appointments; '87% (n=40/46) preferred teleconsultations to being transported to the hospital clinic for their foot care' (Corcoran et al., 2003, p. 148).
Two studies, a case study, and a pilot study, commented on how hard it was to recruit enough participants for surveys due to the frequency of a dementia diagnosis among residents (Bidmead et al., 2015;Hui et al., 2001). Hui et al., (2001) reported that 70% of residents were unable to provide informed consent to participate in a survey due to cognitive impairment . This was a common reason given for low numbers of residents' perspectives included in many studies.

| Nurses' improved assessment skills
Telehealth offered RACF staff the opportunity for a second opinion and supported teaching/learning when a more skilled colleague or clinician was involved in the consultation. A grounded theory study by Stephens et al. (2020) explored the effect of telehealth on the assessment skills and experience of the RACF nurse with the use of telehealth.
'The staff of the residential home found that it increased their knowledge and ability to care for the client. Initially, some were anxious about telemedicine, but after a little experience they became confident and adept at using the equipment'. (Corcoran et al., 2003, p. 148).
This in turn, built trust with the residents because their care was being managed in collaboration with many clinicians (Stephens et al., 2020). Other studies have described telehealth in RACFs as improving staff confidence due to 'Improving nurse assessment skills' (Chess et al., 2018, p. 386;Hui & Woo, 2002;Pallawala & Lun, 2001), increasing professional satisfaction (Catic et al., 2017) and assisting in the avoidance of adverse events (Bidmead et al., 2015).
Whilst seven studies reported on the improvement of assessment skills for staff, only one study questioned whether these skills would be sufficient to assist the recipient on the end of the telehealth call. There were concerns from speech language therapists (SLT) regarding accountability associated with making the correct diagnosis for the resident via telehealth (Bidmead et al., 2015). One

SLT commented
'would we get enough information from the person at the other end of the link to allow us to give safe recommendations?' (Bidmead et al., 2015, p. 6).

| Cost savings
The use of telehealth in cost analyses focused on the reduced travel of the resident to ED and the cost of the specialist travel to the resident (Corcoran et al., 2003;Rabinowitz et al., 2010). In some cases, the additional cost of sending an escort with the resident to ED was saved (Gray et al., 2012), along with the cost of the ambulance transfer. Reported cost savings varied considerably from hundreds of dollars to some resulting in million-dollar savings (Chess et al., 2018;Grabowski & O'Malley, 2014;Hofmeyer et al., 2016), depending on the RACF and the study size. A study by Chess et al. (2018, p. 386) stated there are 'significant healthcare cost savings'. This study found in one year, 91 residents avoided hospital admission, ambulance transfers and Medicaid-covered costs, with a saving of US$1.6 million with the inclusion of a telehealth enabled service. Two studies (Chan et al., 2001;Grabowski & O'Malley, 2014) reported that telehealth was economically attractive, with a study by Hex et al. (2015) reporting a 39% return on investment in the reduction of length of stay in hospital. In a stepped wedge trial, telehealth made an indirect care cost reduction in wound care of US$650 per resident compared to usual care (Stern et al., 2014).

| Enablers
All studies found telehealth to be very acceptable. Studies that included older people (residents), podiatrists, nurses, occupational therapists, psychiatrists, dentists, GPs and geriatricians all found telehealth to be of benefit for several reasons. Reasons included the development of a good working relationship between the GP, nurse and the resident (Ohligs et al., 2020); the GP was able to pass from one resident to the next in almost no time; allowing an efficient use of resources, and telehealth was understood to be an efficient triage mechanism that identified issues in timely fashion (Corcoran et al., 2003;Harris et al., 2021). Podiatrists also found that telehealth allowed earlier intervention for residents and nursing staff who increased their knowledge and ability to care for the resident using visual telehealth (Corcoran et al., 2003).
Telehealth allowed integration within the clinical team and the primary attending physician (Chess et al., 2018); a great benefit to the clinical assessment process. This benefit was realised in that the physician can see and examine the resident within minutes and can initiate treatment or send the resident to hospital in a timelier way (Chess et al., 2018). An efficiency also noted by speech therapists and podiatrists, telehealth allowed them to see more residents (Bidmead et al., 2015;Corcoran et al., 2003). A podiatrist study reported increased productivity; 'Three times the number of people could be screened via teleconference in the same amount of time as required for an on-site consultation'. (Corcoran et al., 2003, p. 148).
In addition, specialists reported that the use of telehealth helped to reduce waitlist assessments for residents (Corcoran et al., 2003;Hui & Woo, 2002).

| Barriers
Two studies indicated that staff felt their workload had increased with the introduction of telehealth (Bidmead et al., 2015;Hui et al., 2001). Along with the perception of increased workload, it was hard to embed the intervention due to staffing issues such as insufficiently experienced staff (Bidmead et al., 2015). The staffing of caregivers in RACFs was hampered by frequent staff turnover and insufficient managerial support (Stern et al., 2014). In addition to the poor staffing, there were issues around provider engagement with telehealth as there was not always a guarantee that RACF staff would use telehealth when offered it. This poor uptake of telehealth was reported by Grabowski and O'Malley (2014)  One study in France reported that there was a difficulty engag- ing GPs with telehealth (Piau et al., 2018). The GP is the primary health provider for residents and their involvement was not reported in many of the studies in this review. Of the 28 studies, there were only three that mentioned GP involvement specifically (Ohligs et al., 2020;Piau et al., 2018;Salles et al., 2017) and not always positively. One study implementing a telehealth pharmacological intervention reported that some GPs; 'refused to implement the proposed pharmacological interventions, which was very frustrating for the staff' (Piau et al., 2018(Piau et al., , p. 1002. Several authors identified telehealth was not always appropriate for physical examinations (Corcoran et al., 2003;Hui et al., 2001;Piau et al., 2018) or procedures like the debridement of a wound (Hui & Woo, 2002;Piau et al., 2018) or other 'hands on' procedures (Corcoran et al., 2003, p. 148). This was clarified in the Corcoran et al. (2003) podiatry study, with authors concurring that telehealth would not always be appropriate because: 'assessment via teleconference did not include indepth neurological or vascular assessment, because of the lack of equipment on site'. (Corcoran et al., 2003, p. 149).
Similarly, geriatricians found it limiting to do a physical examination on new residents and nurses found it was challenging to assess resident behavioural problems (Hui & Woo, 2002). In contrast, a survey of providers revealed that telehealth would reduce avoidable hospitalisation of residents and not weaken their care management plan (Driessen et al., 2016).

| DISCUSS ION
Few RCTs have been conducted that report a treatment effect associated with a telehealth intervention (Grabowski & O'Malley, 2014;Joseph et al., 2020;Kane-Gill et al., 2021;Stern et al., 2014 The review of these studies identified the following issues. Firstly, there was an absence of detail about the actual lived experience of a telehealth consultation and the perspectives of RACF residents (Stephens et al., 2020). Corcoran et al. (2003) reported that residents were often excluded due to a diagnosis of dementia.
Additionally, there was no measurement identified regarding the impact of the seasonal variation on hospital presentations. Only one study acknowledged that there may have been a seasonal confounder (Joseph et al., 2020). Finally, there was an issue in some cases around data accuracy. One study reported there was a problem capturing accurate information with the incorrect categorisation of telehealth cases (Kane-Gill et al., 2021) and missing numbers in another study (Gray et al., 2012).  (Bidmead et al., 2015). Furthermore, in many studies, the sample sizes were small with the sample often drawn from only one RACF, and consequently, results were not generalisable (Chess et al., 2018).
Supportive collaborations with clinical staff and RACF staff using telehealth to enhance access to teaching and learning, knowledge, and skill development, can increase the ability for staff to care for the RACF resident (Corcoran et al., 2003). Telehealth in one study has shown that these collaborations resulted in 69% of consults preventing an ED transfer (Hofmeyer et al., 2016) and hospitalisation was less common with telehealth with 122 cases (24.4%) (Salles et al., 2017).
Not only can telehealth be justified as a way for residents to avoid an unnecessary hospital admission, it has additional patientcentred benefits also. Studies identify high levels of staff satisfaction and confidence with the use of Telehealth (Chess et al., 2018;Hui & Woo, 2002;Pallawala & Lun, 2001). Studies also reported a positive experience for residents in terms of usability and acceptability of telehealth (Chan et al., 2001), feeling less distress (Bidmead et al., 2015) and having increased comfort. Another positive outcome was that the resident and families were involved in the decision-making surrounding the management of their care.
Residents also felt more included in the decision-making with telehealth (Chess et al., 2018) which they felt gave them a better quality of life (Bidmead et al., 2015). In accessing telehealth, residents have an opportunity to be involved in decision-making and a choice in their own health care justifying the use in RACF care pathways.
Hospital avoidance was observed in most studies yet telehealth is not commonly embedded in all acute facilities. Telehealth is not used to its full potential and was viewed in one descriptive study to be underutilised (Driessen et al., 2016). Grabowski and O'Malley's (2014) RCT suggested the reason for telehealth underutilisation may be the need for policy reform to incentivise the use of telehealth with financial remuneration. The cost savings from engaging with telehealth and return on investment has been mentioned in many of the studies. Telehealth is a justifiable investment for healthcare services with the appropriate and cost-effective care pathways for RACF residents.
There is a need to conduct research related to RACF residents to help prevent unnecessary hospital admissions and readmissions.
Telehealth outreach models can further support RACF staff to care for residents in RACFs with the opportunity for enhanced access to teaching and learning to help prevent unnecessary hospital presentations and treat them in the RACF without exposing them to poor outcomes in acute facilities.
Most recently, the COVID-19 pandemic has been a catalyst for the increased use of and need for telehealth. The pandemic has unfortunately claimed more lives in the RACF-resident cohort than in any other age bracket (Burkett et al., 2021). Clinicians are looking for ways to facilitate assessment from a distance, whilst keeping the care recipient front and centre of their care during the pandemic.
The telehealth model of care (MoC) provides an effective and viable alternative for clinicians.

| Limitations
Some studies did not recruit a representative study sample, and their results were potentially affected by some bias and consequently were not generalisable. We have added this statement below to the limitations as suggested. No a-priori protocol was registered or published in relation to this scoping review, which is a potential limitation of the study, since a protocol aims to limit the occurrence of reporting bias. Instead, a detailed plan for the scoping review was developed with the first author and supervisory panel of academic researchers who are co-authors. Engagement of a senior university research academic librarian/information specialist guided the search for literature aimed to ensure a sufficiently robust search was undertaken and no relevant studies were missed. Abstraction of relevant data from each paper was scrutinised by the supervisory panel as described in File S2-the use of the PRISMA-ScR (Tricco et al., 2018) enabled the authors to check whether the scoping review conformed to this reporting standard.

| CON CLUS ION
This scoping review has mapped evidence that telehealth has been widely used in multiple settings. The association between the use of telehealth and improved clinical outcomes highlights its potential utility in enhancing care delivery for an older population in RACFs.
Telehealth has shown that it can improve the decision-making for residents in RACFS. Even though the studies were from a variety of different disciplines, hospital avoidance was increased. The review identified that telehealth is underutilised in RACFs. The use of telehealth in RACFs has potential for improved decisions about transferring residents and significant cost savings to hospital prior to, and during a pandemic.

CO N FLI C T O F I NTE R E S T
The authors declare no conflict of interest.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.